Healthcare Security & Safety DIRECTIONS

Volume 22, Number 4, 2009

Publication of the International Association For Healthcare Security & Safety

SPECIAL REPORT

New Trends in Evacuation Planning For Disabled and Special Needs Patients

Managing and training for the evacuation of disabled and special-needs patients in hospitals and nursing homes has taken on a new urgency since the 9/1 1 and Katrina. The shortcomings demonstrated in those disasters and in other incidents have spurred investigations and the acceptance of new approaches reviewed in this report. These include the need for backup power for central air conditioning; the use of elevators in fire emergencies; replacement of cumbersome chairs and blanket-carrying procedures with lightweight, heavy duty sleds; and the virtual recreation of a hospital or nursing home to train employees in evacuation techniques.

LAWRENCE AND MEMORIAL: FACING A REAL EMERGENCY, NOT A TEST

In what became something of a textbook primer on evacuation complications, administrators at 280 bed Lawrence and Memorial Hospital, New London, CT, found their emergency preparedness plans sorely tested when a fire engulfed all three of the hospital’s electrical transformers. The August blaze, which started in one transformer and quickly spread to the others which sat side by side in the same room knocked out electrical power, and a backup generator proved insufficient in restoring full electricity. The hospital was not completely back on line until 48 hours later.

Disabled and special-needs patients were given priority evacuation to areas of the hospital that were not affected by the thick black smoke emitted by the transformers. Patients in vulnerable areas of the hospital who were immobile or had other special needs where wheeled to safe areas by gurney and wheelchair. Ron Kersey, Emergency Planning Coordinator at Lawrence and Memorial, says patients were moved from five inpatient units into several outpatient areas, including the emergency room. “An awful lot had limited or no mobility,” he reports.

The smoke spread quickly from its source, but emergency responders were able to contain it by closing fire doors that kept it out of main patient areas. The Aug. 11 fire burned from about 10 a.m. to 1 p.m. as firefighters struggled to contain it because of its intensity and its electrical nature and because it took the utility company a considerable amount of time to disconnect power to the transformer vaults. No injuries or deaths resulted from the blaze, but Kersey says that the timing of the fire in the heat of midsummer exposed patient vulnerability to the sudden loss of air conditioning. Public-health officials brought in mobile air conditioning units, but central air was not restored throughout the hospital until the next day.

Review Of Emergency Response Finds Room For Improvement

A review of the emergency response to the fire found room for improvement in certain areas, Kersey adds.

- The lack of an immediate backup power supply for central air conditioning. “It was a 90 degree plus day outside with 100 percent humidity and our chillers were not on emergency power,” Kersey notes, adding that the hospital has set aside a weekend later this year to implement a switchover that is cumbersome and expensive but that will correct the problem. “This isn’t a situation that’s unique to hospitals, but the first lesson that should be learned here for any hospital is that if your chiller plant is not on emergency power, you might want to start looking at that.”

- A lack of clarity among hospital staff on where exactly to take patients during an evacuation and where evacuated employees should gather if they were required to leave the building. “Not everyone had a clear guess as to where they were supposed to take patients ... and one big lesson that we learned was that you need an accountability area outside the facility so that you can have everyone in one location when you want to get them back into the facility as needed.” The hospital is now updating and clarifying its evacuation protocols.

-Command center confusion. “We realize we need to command better from our incident command center ... things like how people know what their job is and how to communicate with other hospitals, which were poised to help and weren’t getting the word from us.”

Kersey notes that a hospital’s electrical supply is its lifeblood: “We weren’t a community hospital for about 48 hours.”

A MORE ROBUST ADVOCACY FOR EVACUATION OF THE DISABLED

Disaster often proves the catalyst for emergency preparedness, notes Patricia Pound, First Vice Chairperson for the National Council on Disability (NCD), and Chairman and Executive Director of the Texas Governor’s Committee on People with Disabilities. The tragedy that unfolded in the wake of Hurricane Katrina in 2005 underscored what can happen when emergency preparedness falls short, she says. Scores of disabled and special-needs residents and hospital or nursing care patients in and around New Orleans perished in the days after the storm because of evacuation failures throughout the area, she claims.

“It opened a lot of eyes,” Pound says, and NCD, long active on the issue, stepped up its campaign for better emergency preparedness and evacuation after Katrina. It found a public more willing than before to listen to its arguments, says Martin Gould, NCD’s director of research. “Awareness is spreading,” Gould says, “but there’s still a lot to do.”

In August, NCD, an independent federal agency whose 15 board members are appointed by the president, issued a report, Effective Emergency Management: Making Improvements for Communities and People with Disabilities, whose genesis was in the response to the terrorist attacks of 9/11, but which took on even more weight after Katrina. Its intent:

“To identify how people with disabilities appear in the emergency management paradigm...to find out what exists or doesn’t exist on this topic.”

Report: Evacuation Procedures For Disabled And Special-Needs Patients Are Typically Overlooked

The report found generally that emergency evacuation procedures for disabled and special - needs patients - even those in outpatient care - are typically overlooked or underemphasized. “The greatest amount of work has been done in the area of disaster preparedness but there’s need for more regarding education/training, planning, design of warnings, and sheltering services,” the report says. “Emergency managers are often not prepared for serving people with disabilities due to burdens on minimal staffing; people with disabilities often are not prepared for disasters due to their challenging life circumstances.”

Among the report’s more principal assertions:

- “Most emergency management planning occurs without input from disability organizations or people with disabilities.” “More attention needs to be given to the needs of people in nursing homes; people who do not drive or do not have cars; people who need general or functional-needs shelter services.”

A Source of ‘Promising Practices’

The report found what it called “promising practices” as well, citing the aggressive education outreach encouraged in New Jersey by the Progressive Center for Independent Living, which is a member of the New Jersey Special Needs Advisory Panel and actively promotes its web site links to emergency preparedness and evacuation information on its website. Working with the New Jersey Council on Developmental Disabilities, the Center has collaborated on a training program for “community disaster liaisons” which then spread their knowledge and skills with disabled residents and patients and with first responders. The NCD says the New Jersey effort “demonstrates that grants that require partnerships linked to the grassroots level can have beneficial results; involving disability advocates and organizations in outreach efforts is key; and the train-the-trainer approach can work with disability populations.”

The NCD report also includes core recommendations. Among them: -“Give priority consideration to people with extraordinary health care needs and life-sustaining dependence on electrical equipment. Establish systems to register with electricity providers.”

- “Involve disability community organizations and state offices or agencies in all state efforts regarding natural hazards, terrorism, technological or hazardous materials concerns, and pandemic planning.”

ELEVATOR EVACUATIONS: A BREAK WITH TRADITION

As awareness of the special challenges confronting the evacuation of disabled residents and patients grows, so too have doubts about certain traditions. Elevator evacuations, long considered taboo, have quietly gained support as emergency management professionals see the advantages under certain clearly defined circumstances. This trend is documented in the NCD report, which notes that in Washington State a movement is under way to allow elevator evacuations. The report cites a speech by Dave Beste, a captain with the Bellevue, WA, Fire Department, at a quarterly meeting of the NCD in Seattle in 2008.

Beste notes that several organizations by necessity are involved in the movement because elevator safety standards are of vital interest to so many otherwise disparate groups, including disabled people and their representatives. Among them are the National Institute of Safety and Technology, the American Society of Mechanical Engineers, the International Code Council, the Government Services Agency, fire-safety groups, and the elevator industry. As a member of a state task force on the topic, Beste outlines how advocates of allowing elevator evacuations have framed their case. “Elevators would be programmed to stop running once a smoke detector sounded; however, they would go to the affected floors. Once there, individuals trained to use the elevators would aid people with disabilities in evacuating the floors affected by fire. The fire department would be able to use all the elevators for this purpose or only some of them. Furthermore, with the use of ‘pressurized stairwells,’ air pressure would prevent the smoke from leaving the floor and going into the elevator or lobby. Finally, audio and video signage would direct evacuees from the building in a safe manner. A two-way communication system would be installed in every elevator lobby, and a person on any floor could call fire control for assistance.”

Elevator Use: Adopted in Washington State; Interest Is Growing Nationally

In an interview this fall, Beste said the project has moved forward since 2008 and that Washington State now allows elevator evacuations “under certain criteria,” which generally include the description above but also require code certification and sign-offs by various regulatory agencies. It may yet take a few years for the elevator-evacuation taboo to be formally reversed nationally, he said. There is considerable momentum already evident as industry groups get on board. After public hearings in 2008, the National Institute of Safety and Technology rewrote its evacuation codes to allow for elevator use during fire emergencies.

‘PARASLYDES’: A LOW-TECH SOLUTION AT A MONTANA HOSPITAL

At seven-story 235-bed St. Patrick Hospital and Health Science Center, Missoula, MT, administrators this year opted for an evacuation solution marketed by Stryker, Kalamazoo, MI, a global medical technology company. With its purchase of Stryker ParaSlydes, the hospital has invested in a simple product that is relatively new to the market but appears to be catching on, the manufacturer says.

“Like any other hospital, we had an evacuation plan,” says Leanne Vreeland, the hospital’s Director of Safety and Emergency Preparedness. “In years past it was pretty much, ‘call the fire department and prepare the blankets.’

“ Previous protocol, she adds, called for moving immobile patients to safety by transporting them with blanket slings carried or dragged on three points by staff members. “But a lot of nurses are women who are smaller in stature,” notes Vreeland, and the practicality of such an evacuation plan was always questionable. Several months ago, the hospital bought 60 ParaSlydes for about $250 apiece, and Vreeland distributed 10 of to each of the hospital’s main nursing stations. It augmented the ParaSlydes at a ratio of one to 10 with a larger version, the Baraslyde, for bariatric, or obese, patients.

The slides come with a belay system designed to lower them down stairwells, and Vreeland says the idea is for floor staff to slide immobile patients to stairwells and then to have maintenance and housekeeping workers take them down. She says the slides are compact “they’re in a zippered pouch and they fold and unfold like a box,” and that they are lightweight and sturdy. She cites a drill done recently by the Missoula Fire Department, where firefighters borrowed one of the slides and put it through a rigorous workout. “They said the took at least 60 people down a stairwell with it - and some of them were big people - and it’s still in fine condition.”

Stryker’s marketing material describes the slide as “a cost-effective, intuitive emergency sled for evacuating non - ambulatory residents or patients from any multi-floor building using the stairway,” and says it is meant to “efficiently speed the evacuation while maintaining organized communication and control. Combined with Belay, system attendants are able to easily control the descent of heavier individuals.”

Nate Walkingshaw, a Stryker Vice President of Development, who also invented the ParaSlyde, says interest has been strong among hospitals, but that nursing homes have not been as quick to sign up, “and nursing homes and skilled-nursing facilities are, candidly, in need of it most.” Walkingshaw, who did much of his development research for the ParaSlyde in conjunction with Salt Lake City-based Intermountain Healthcare, says also that demand is driven in part by a desire to replace heavy and unwieldy “evacuation chairs” that are used by some hospitals.

THE VIRTUAL WORLD: AN ALTERNATIVE TO TABLE TOP EXERCISES AND ACTUAL DRILLS?

Administrators at Children’s Memorial Hospital, Chicago, IL, have turned to an elaborate but easy-to-use computer-based simulation that recreates a virtual model of the hospital as a way to train staff in emergency management and evacuation standards.

Built on the web-based Second Life platform, a three-dimensional virtual world that is popular with games enthusiasts, hospital employees create avatars through which they play their emergency-response roles. “It has proven to be a very effective way to train staff,” says Mary M. Crulcich, the Hospital’s Manager Of Environmental Safety and Emergency Management. “It’s extremely engaging and users are able to practice their decision-making in as real a life setting as possible without the risks. Our virtual world hospital can be replicated over and over and over again without any additional cost.” Crulcich points out that the exercise “is not a game it’s a learning tool, and we also see it as an innovative way to learn we’ve found that by acting our scenarios in the virtual world we get a more engaged type of employees.”

The Second Life project at Children’s Memorial is built around a detailed rendition of the hospital that is based on its original blueprints and recent photographs, and was designed by Centrix, a local firm. Its depiction includes exterior features down to sidewalk details and interior ones that show doors, workstations, room parameters and corridor minutiae. “It’s so realistic, it’s amazing. Streets outside are exactly like they look like in the real world. You turn down a hallway, there’s a door there in the virtual world just like the real world.”

Much of the funding for the project came from the Department of Homeland Security and the city of Chicago, where the Department of Public Health maintains a parallel presence through its own Second Life portal. One of the big selling points for the Second Life project was in its replacement of table-top exercise, which Crulcich says aren’t as engaging. A virtual drill is also a practical alternative.

Crulcich reports that skeptics argued that the computer-simulated drills would be too hard to learn and that older employees would be especially resistant to such techniques. Both doubts were quickly dispelled. “I get this question all the time, people saying this will only would work with staff in their ‘20s, but that’s not true. It works with all ages. We gave them absolutely no advance training, brought them into the lab, gave them a 45 minute orientation, taught them how to move their avatar and within 45 minutes they were all able to pick it up.”

Nurses, security officers and administrator have taken part in the group drills on Second Life, which allow for off-site real time observation by managers. Crulcish says her suggestion for hospitals considering Second Life drills is to find a reputable vendor to create an accurate virtual model of a facility and then to partner with community groups that may already have a Second Life presence, including local universities, police and fire departments.

FOR FURTHER INFORMATION, CONTACT:

Ron Kersey, Emergency Planning Coordinator, Lawrence and Memorial Hospital, 365 Montauk Avenue, New London, CT 06320. Ph: 860/442-071; Email: rkersy@lmhosp.org

Patricia Pound, First Chairperson, the National Council on Disabilities, National Council on Disability, 1 33 1 F Street, NW, Suite 850 Washington, DC 20004. Ph: 202/272-2004 Email: dpound@austin.rr.com

Martin Gould, Director of Research, the National Council on Disabilities, National Council on Disability, 1 33 1 F Street, NW, Suite 850 Washington, DC 20004 Ph: 202/272-2004 Email: MGould@ncd.gov

Dave Beste, Bellevue Fire Department, 766 Bellevue Way SE Bellevue, WA 98004-6654. Ph: 425/452-6892 Leanne Vreeland, Director of Safety And Emergency Preparedness, St. Patrick Hospital and Health Science Center, 500 West Broadway Missoula, Montana 59802. Ph: 406/543-7271

Nate Walkingshaw, Senior Manager, Stryker, 2825 Airview Boulevard, Kalamazoo, MI 49002. Ph: 269/385-2600. Email: nate.walkingshaw@stryker.com

Mary M. Crulcich, Manager of Environmental Safety and Emergency Management, Children’s Memorial Hospital, 2300 Children’s, Chicago, IL 60614-3363. Ph: 773/880-4000. Email: Email: MCrulcich@childrensmemorial.org